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yjj5cal5l n k-yr al <br /> ._.. .. -... .._ ._ . <br /> S and Buildings Division CountyWa <br /> 201 W.Washington Ave.,P.O.Box 7082 /3 <br /> Madison,WI 53707-7082 Site Address ^� <br /> Depar�,t77ment of Co.•m77merce .30/3 3AS41ar..) LAK£ 1-.P qk <br /> Number <br /> u <br /> t N <br /> Sanitary Permit Application Sanitary Permi4tN <br /> In accord with Comm 83.2 1,Wis.Adm.Code,personal information you provide ❑ Check if Revt onq -7-7 / J <br /> maybe used for secondary purposes PrivacyLaw,s 15.04 1 m <br /> I. Application Information-Please Print All Information State Plan I.D.Number <br /> Property Owner's Name Parcel Number <br /> 66E t <br /> Property Owner's Mailing Address / / Property Location <br /> 30/3 FIS 1-kZ 1-i14kV4 /:S T3 N R GIIJ <br /> City,State Zip Code Phone Number Lot Number Block Number <br /> L <br /> / Subdivision Name CSMNumber <br /> c5hett CAKE (,�� 5YF7/ V3y P3(olA <br /> Il.Type of Building(Check all that apply.) [ City <br /> 01 or_I-amik Dsceiling-Number of Bedrooms -31 S�S�aa�, ❑Village <br /> p PubhC/Conunercial-Describe Use ZTownshi <br /> ❑State(honed Nearest Road <br /> SNS LAKf- �i <br /> Ill.Type of Permit: (Check only one box on line A. Numbering is for internal use.) (Complete line B,if applicable. <br /> A 10 mere � 3❑Replacement of 6❑Addition to For County use <br /> Replacement SN stem Tank Ort! Esistur System <br /> Scstcm <br /> -- <br /> H' ❑Check it Sanitan Permit Preciously Issued Permit Number Dene Issued <br /> I V.Type of POWT System: ( hek all that apply. Numbering is for internal use.) <br /> 44jX Non-Pressurized in-Ground(/_ ,sfl 21[]Mound 47 ❑Sand Filter 50❑Constructed Wetland <br /> 22 ❑Pressurized In-Ground // 41❑Holding Tank 48❑Single Pass 51❑Drip Line <br /> 45❑At-Grade 46❑Aerobic Treatment Unit 49❑Reeiroulating 30❑Dther <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade <br /> Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation <br /> 4/6;t> 6, loCR af z- .17 /Nor /d/. op r 10-117 <br /> VI.Tank Info Capacity in Total Number Manufacturer Prefab site Steel I Fiber Plastic <br /> Gallons Gallons of Tanks Concrete Constructed Glass <br /> New Existing <br /> Tanks Tanks ' <br /> ep' or Holding Tank Ooo <br /> osis hamber <br /> pp -- <br /> j <br /> VI 1. Responsibility Statement- 1,the ndersig d,assume sponsibility for insta11 t' of the POWTS shown on the attached plans. <br /> Plumbers Numc IPr;np lumber' Signature MP umber Business Phone Number <br /> M&K SEPTIC & EXCAVA as Ysl7 S <br /> Plu -•; �. el --- ----i <br /> SPOONER, WI 5480 <br /> �! VII[.County ear e t e Onl <br /> LJ Dsap eift' Da[ Iss lssuin Ag m. • tamps) <br /> �4Approced ❑Owner Given Initial Adverse Sur;ta r Permit Fee(ig�udes GryyndcgaZgr CIA <br /> Surcharge Fee) jj��JJ /erFLilldt/tY�i/U <br /> Determination <br /> IX.Conditions of Approval/Reasons for Disapproval <br /> RECEIVED <br /> -- 2000 <br /> Atta4dt romple0e plain(to We CormtY on1Y)for the pia m 81!1:11 iodtes t0 aYe <br /> BURNETT COUNTY ' <br /> ZONING <br />